Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Thursday, October 04, 2007

The Student Prints

I like med-student blogs. They remind me of the excitement, the frustration, foreboding, and fun of those times. More than that, from the quality of the writing and the depth of the thoughts expressed, it gives me hope that when I'm sick there may still be doctors out there interested in taking care of me in the way I'd have taken care of them. On the other hand, some of what I read is disturbing.

It's a predictable pattern: someone writes about her/his surgery rotation, and -- if not perfectly word-for-word -- certain statements will be made, and an inevitable array of comments will follow. The cast of characters is always the same: the asshole resident, the overbearing and brutish professor, the student who hates everything about it, sometimes with one or two who love it (and whose motives and sanity will likely be challenged.) Rarely, there might be a supportive resident or two. The behaviors described recur time and again. Berating, humiliation; a senior attending who not only treats the students and residents like shit, but his patients as well. The author, and the commenters, in the most vituperative and unforgiving of terms, validate their owns similar experiences and roundly condemn the surgeons and their method of teaching.

Keep your fingers off the keypads for a minute, kids: I'm with you. The reason this is disturbing is that it's true, and I hate hearing it. By far the worst thing to read -- and I've read it in commentary by patients as well -- is the description of a doctor (any doctor, but particularly a surgeon, because they seem to be the most frequent offenders, in these fora, anyway) being disrespectful and uncaring toward a patient. For that, there's no excuse, ever. And whereas I don't think for a minute that it's limited to academe, I believe -- from observation -- that such behavior is more common within the ivory walls than outside. Maybe it's tenure; maybe it's the academic rat-race; or maybe it's slop-over from the anti-Socratic method of discourse that's become embedded in surgery training like dogshit in a Doc Martens.

The operative phrase is "shit runs downhill." Profs dump on the chief resident, who dumps on the senior resident, who dumps.... But it needn't be like that. I wasn't like that.

In training, as I worked up the ladder, I was a good and patient teacher (or so I'm saying!) I had interns and junior residents over for dinner; I made jokes on rounds, and pitched in on the scutwork. I relished showing technique and explaining reasons for things. I rarely -- if ever -- grilled, and when I did, it was to get somewhere rather than to debase. It can be done. I don't recall chewing someone out, ever. But when I became a real doc, bearing all the responsibility myself, some things changed. I NEVER treated my patients with anything less than respect and empathy. But I know I could be hard on the nursing staff, and even referring docs, when I thought something had been done less perfectly than I demanded of myself. Believe it or don't, I was much harder on me than on anyone else if anything diverged from my view of excellence, but I make no excuse (OK, I do: it was based on hyper-perfectionism and not arrogance): things can be said in less off-putting ways. (In fact, in my second incarnation, after brief retirement and time to relax and reflect, as a surgical hospitalist I had an entirely different attitude. Nurses who'd known me before said they'd never seen me so happy. I think it partly had to do with sleep. And, yeah: being old and beat up enough to let some things go.) But there's a point here.

Not everyone will buy it without offense, yet it's true: surgery is the court of last resort. A surgeon is judge, jury, and -- God forbid -- executioner. Every other doctor can punt, and they do. Often. A surgeon can't, especially in the OR. And so, whereas it needn't be as punitive and degrading as it is in some places, surgery training will always be long, and hard, and demanding. I accepted a certain amount of misery when I went through it (and worked hours far more brutal than now) because I felt urgency and necessity. I thought then, and still do, that surgery training does more than the others to inculcate a sense of responsibility, the knowing of one's limits, and a commitment to perfection; and it must, because there are no hiding places in an operating room. If some students are put off by it, it's not entirely a bad thing. They will, and should, make another choice.

I read a student blog the other day. The writer said she hadn't read up on the operation in which she'd be participating, and was taken to task by the operating surgeon. With relish, evidently. Her post was followed by lots of comments deriding the attending in particular and all surgeons in general. There was an echoing chorus of animus: they're dehumanizing, bunch of egomaniacs, surgeons are terrorists. But along with the cringe of embarrassment for being associated with the evident scum of the earth, there was a twinge of an opposite thought: if I were to show up to an operation unprepared, someone might die, or be maimed forever. I'd hope that people who choose to become surgeons are the sort that don't need reminding, and are, in fact, the kind that wouldn't show up unprepared in the first place. But in training, some do. And they don't last. If they don't respond to whatever method the attendings or the senior residents bring to bear to point out and correct their failing, they get tossed. As they should. And, as someone who might some day lie on a table in the most vulnerable position you'll ever be in, aren't you glad to know that?

30 comments:

Great post. This is the era of the Coddled Doctor-in-Training. Everything from work hours to how attendings interact with students/residents is under intense scrutiny and reappraisal. Lifestyle seems to be the overriding theme. Am I getting enough sleep? Do I come home too late? Am I treated well at work? Are people rude to me? Am I receiving enough positive reinforcement? Me me me me. What about that patient on the table or moaning in the ICU bed? When are their needs addressed? People don't get it. This is a career that demands self-sacrifice and humbling yourself before powers you'll never understand.

Oh, by the way Doc. You wouldn't happen to be a UW Husky fan would you? Because, my Bucks went out there and smoked 'em.

Well, I grew up in Oregon, and went to a Div 3 college (played a little football there, and a lot of rugby.) Having lived in WA for 25 years, yeah, I pay attention to the Huskies and root, to the extent that I am the rooting type. Guess I'm in the Div 3 of rooting. But I sort of still like those Duckies.

i like the balance that sid brings to the force. i too never treated others with less respect than i would have liked.but as buckeye says, for those of us going to become surgeons, the bar must be higher. like any true surgeon i also was harder on myself than anyone else. the prevailing thought of poor me in training today i do not think is good. and yet, like sid i cringe when i hear how some socially maladjusted surgeons go at their juniors. shit may run downhill, but it always stopped at me, as it should be.

sid, on rugby, i hope you are watching the world cup. my team has a very real chance of taking it this year. all blacks might be a bit tricky

Coming from a student-in-training, I agree with everything you said. I think the key word here is "balance." When you are training, particularly for such a demanding field as surgery, your life will not be in balance. That is the nature of the beast. Those who want good lifestyles as a resident need to pick a specialty that affords them shift work or what have you.

Balance must also be attained by the attending. To point out a trainees flaws is necessary; even some "dressing down" is often required when the situation calls for it, to ensure the point is learned. A good teacher takes the trainee to the precipice to show them what could have happened, not push them over the edge as though it did.

Finally, another reason things change so little is the obstinate mentality of "that's how it was in my day." How absurd, advertising one's own lack of evolution. Each successive generation should take the mistakes learned and ensure they aren't repeated.

I don't know who's blog posting you read, but if the student was not a sub-intern, and was not planning on going into surgery, the attending berating her for not knowing the surgery is ridiculous.

As a medical student, you show up on the day and do what you're told. I often had no idea if I'd be staffing clinic or the OR, and often my job consisted of suctioning or retracting if I was lucky; otherwise I just stood there. If you're not going into surgery (and most med students aren't), it would be much more useful to spend time managing surgical patients in the ED, clinic, floor, and ICU than learning how to do a particular type of surgical procedure. Sure, you learn a bit from the anatomy being in the OR, but it's pretty low-yield learning otherwise. If the student is interested in going into surgery, then absolutely, read up because you want to.

The student should understand the anatomy and the concept behind the surgery, but there's no reason (ie: it serves no purpose) to berate a student for not knowing the anatomy.

I think I know whose post you're referring to (I'm a new blogger there as well). While you make excellent points, Dr. Schwab, about medical students needing to stay on top of things, especially for surgical cases, I'd tend to side with Graham and say that there are better ways to go about reprimanding students if they happen to be unprepared than flat-out insulting their intelligence. Perhaps that's the student in me, though.

So glad to hear, though, that you've avoided these exercises for the most part and seem to have done so proudly. It seems as though this very episode is precisely why the whole of surgery gets the reputation that it has but that there tends to be an isolated bad bunch that spoil it for the rest (not unlike medicine itself).

I remember one time in the office explaining what neurologist is, and had to answer that no, I don't do surgery. The patient responded, "Oh, so if there is a problem, you don't do anything."I think there was a pause on my part, after which I just said, "Uh, yeah" and left it at that.

I guess now that I've laid out my humility in my previous comment I can come to the "defense" of nonsurgeons by saying that in some cases surgery can be done with no positive or negative consequences. I saw a patient recently who previously had some pain in roughly the right lower chest area, eventually ended up having a resection of some lung tissue, all for naught. Another came in and said, "Well your problem really was coming from your gallbladder," and since it resolved with some antibiotics, it was not felt that cholecystectomy was necessary.

Great post Sid. I always like your posts even though I am far more conservative than you.

I have never understood why Docs can be arrogant and condescending to their patients. One, they are the source of your income; two you piss 'em off and they tell their friends and a bad reputation gets around quickly; three, have a great bedside manner and you are less likely to get a summons.

Graham, I'm an OB/GYN doc on a teaching service. Our students know in advance what cases I'll be doing in the morning and I expect them to have read up on the anatomy. I expect them to have read the H&P (often they were at the pre-op visit). So I expect them to have read up on fibroids, endometriosis, family planning or malpresentation or whatever. I hate it when a student states that they don't know the anatomy because they had it 2 years ago. I don't yell at them, but they do earn some displeasure.

And Graham, its not low yield learning in the OR. Even if you don't go into a surgical specialty, you'll be much better able to advise your patients who may ask you about your opinion on having surgery.

Finally Sid, the general surgeons always give me a hard time about pfannelstiel incisions.Tomorrow I have to do a section on one of our general surgeons whose baby is a double footling breech. Think I should ask her if she wants a midline incision... :-)

storkdoc: good comment. And most of my colleagues are more conservative than I; I can handle it (although, as I've said, it's real conservatives that ought to be in the streets with pitchforks and torches over what's going on at 1600 Pennsylvania Avenue.) On the other hand, I actually made a couple of Pfannenstiels in my career.

Here I am in a little village where the doc turnover is high. The only guy who stays is the one who owns a clinic or most of it. He is rude to Medicare patients -- not to others.

The most recent "passing-through" doc saw a former student of mine -- now a grandfather -- who has managed to struggle through an aneurysm deep in his brain: deep enough that they had to go in through his temple, pushing his eye and other things out of the way and removing a big piece of skull temporarily. This man functions through grit and intelligence. He can't make his eyes track to read now, so he listens to books.

When the latest passing-through doc saw him, he cheerfully announced that he hadn't bothered to look at his patient's file. PTD was surprised that his patient became angry... But, ya know, seems like the doc could try as hard as the patient.

Graham's comment got me to write this follow-up--I didn't mention in my other comment to save space. I stand by everything I said, but it really was in the context of residents or "serious" trainees. For med students, the purpose of these rotations is to learn the basics (and anatomy is about as basic as you get for surgery, though often pedantic) of a field and see if it's something that interests you (or that you dislike the least...heh). Unless they are gunners who feel called by God to do surgery, it's less about impressing the attending with your encyclopedic anatomical/procedural knowledge than showing seriousness to learn, making the most of one's opportunities, and being part of a team--just like almost all rotations.

Developing somewhat of a thick skin is also part of the training. It's way easier if you're older like me, but should a surgeon ask me questions until I don't know any more, then continue, then insult me for not knowing, then continue with even more obscure questions, I'd have no problem firing back, "You can keep asking more detailed questions and watch me guess randomly all afternoon, but I fail to see what that is going to accomplish. I apologize for not knowing the level detail you'd like, but I would actually like to walk out of here at the end of the case having learned something if you wouldn't mind sharing." No problem whatsoever.

Not knowing something you know you should have had you only worked a bit harder is different, as is simply drawing a blank on something that you did know and just couldn't recall at that moment. Aside from outright verbal abuse, "shame" that one often reads in med student blogs for not knowing trivia is self-inflicted and usually serves little purpose. Accept that you will make mistakes, learn from them, and move on. That's what training is about.

Great post, Sid. Isn't it interesting that the scenario you describe (ranting attending, brutal chief, humiliated student, etc.) is a recurrent theme? The blogs confirm that it echoes across all continents and in every medical school. Interestingly, the same social dynamic has been described by generations of physicians including Chekhov, Williams, Selzer, and Groopman.

Sure, we’re always amazed when a resident or student shows up unprepared – we love what we do, and our selective memories have long since forgotten the times, years ago, when we reviewed the wrong chapter or forgot what we had just read. It happened then and it happens now.

As we ascend the food chain, we physicians remain at high risk of becoming all too full-of-ourselves. My hunch is that today’s students will likely continue the cycle in their own good time unless they understand their own history.

"I don't know who's blog posting you read, but if the student was not a sub-intern, and was not planning on going into surgery, the attending berating her for not knowing the surgery is ridiculous."

I'll agree that if the student was unexpectedly sent to observe the surgery then it was inappropriate to give him crap, but a student who knows he's going to a particular operation and does not even bother to do even a little reading about it deserves to be made to feel at least a little uncomfortable about his lack of preparation.

And not criticized about not knowing the basic anatomy in an operation? Please. Did the student not take anatomy as a first year? I've had students who can't even tell me what artery goes to the appendix or the gall bladder--or even what the blood supply to the colon is. Very basic stuff. We're not talking pointing out tiny named nerves that they'll never need to know.

My philosophy is that I pay as much attention in proportion to the level of interest that student shows in the material, after first giving a generous evaluation period to see how interested he is. If a student shows a lot of interest, I'll definitely spend a lot more time teaching him. Lackluster students who can't be bothered to read about the basics of basic bread-and-butter operations during their surgery rotation waste my time and don't appreciate my teaching effort anyway.

I think I agree with most of the posters, it's just the depth of knowledge that I sometimes find a bit ridiculous.

Absolutely if the student knows who he'll be operating on the night before, he should prepare by reviewing the basic overview of the surgery, the relevant anatomy, and know the patient's history, presentation, and physical. That's a no-brainer.

As a medical student, you should know the basics at the very least, since we're here to learn the basics of how different specialties practice. Absolutely. If a patient has endometriosis, and you don't even know what endometriosis is, yeah, that's a problem. But nit-picky stuff done not for learning but for making the attending surgeon, with 15 years of experience under his belt, look good at the expense of the medical student who's been on the rotation for two weeks? Absolutely unnecessary.

So is this the era of the coddled student?I precept 1st years in my family practice office. I start on time at 8:30. My student was late two weeks in a row and knocked to come in half way through the physical. After the second time I spoke with her after the end of the morning. I suggested promptness. To motivate her I showed her who was on the schedule the following week for a CPX. Fascinating case of "Subjective blindness"...another story...anyway, the next week she shows up 1/2 hour into the physical. Knock on the door... I asked her to wait in my office. After the physical I suggested she go home...I got a call from the Program Director that afternoon suggesting I not be so hard on her.I think I was appropriate. I think she'll have some problems down the road.

Speaking purely from a patient's perspective, I am not sure who all these mean doctors are. Maybe I've been very lucky to come into contact with doctors who are all very kind and most importantly capable. I know many people, some in my family and some close friends, who have horror stories they love to tell about an aweful surgeon or cruel family doctor. I sometimes wonder if most of these stories have not been exaggerated so they'd have an interesting story to tell while out for lunch with friends. The worst I can say about my experiences with doctors has been that when I've had each of my three kids, they were sick. Not as sick as some babies but still sick enough to be in hospital. Every single time I took one of my newborns to the hospital, I was perceived as the "crazy, overprotective new mother". I insisted and every time I was right. My first had a staph infection on his tummy and my second and third had nasty kidney infections because of kidney reflux. But other than that, doctors I've known have been great. I recently saw a surgeon who was amazing. I was very pleased with the way he explained things to me, took time to answer every one of my questions without making me feel like I was wasting his time and the most amazing thing of all.....I only had to wait a week to see him. I couldn't believe that. The waiting lists around here to see specialists is months and sometimes years long. I am not sure how I got an appointment in only a week (it's not like I was THAT sick) but I did and I appreciate it. Oddly enough, his wife is my son's nephrologist and she's awesome too. I once accidentally called her at home rather than leaving a message at her office (which was my intention) and she wasn't the least bit put off by it. She's been so great for my son that I can actually say I love her.

It's about teaching people to develop habbits of professionalism. Sure, if you're a psychiatrist, you may never need to know about vascular supply of the colon to do your job, but you need to have the habbit of coming in every day prepared to do whatever it is you have to do to take care of patients.

The principle is not one of the specific knowlege, but of dedication to the profession. I think that the work hours limits are good, but you still need to study, read, a little bit of something, every day. Get a little better, a little smarter every day, otherwise you get left behind.

As a student who loved his surgical rotation, seriously entertained thoughts of becoming a surgical resident, and pondered long and hard between two different but similar fields (both in the OR and both care for ICU pts) I finally had to look at it a different way.

Being as hard on myself as I am and knowing the level of expectation I place on those around me as well as myself I knew I would not be around for my family. To me this is the most important role I have in life. If I failed as a parent and husband because of pursuing a field that demands the most in medical training then I failed everything. Because of this notion I decided to take the other path.

I know several students think of surgeons as assholes. Some simply are. Others, based on their personalities and training, demand more from others than people might be accustomed. Is it wrong? Certainly not.

Through reading your blog and some others and yes some TV med shows, I have kind of figured that the intensely grueling training that you surgeons endure along with your personal drives, i.e., perfectionism, hyper-vigilance, etc. is like the marine boot camp of the medical field. Really...it does all fall on the surgeon in the OR. (Anesthesiologist too?)

I can't truly fathom the awesomeness coupled with responsibility that you as surgeons experience. (Taking Trust Oct 7th still one of my favorites) I would think that the weak/incompetent (for THAT field) SHOULD be weeded out.

I don't say that callously BTW, just that if I or a loved one were on the table...I'd want the surgeon with MOXIE!

Of all the docs that I have ever worked with or known...the surgeons are the "crankiest" but NOT always-there are exceptions. And there is one surgeon I am thinking of that I NEVER saw lose his cool and the one time I saw he was pi**ed...(in the ER) the pt never knew and in my opinion-maybe he should have. I actually have a funny specimen story about him that ties in with his laid back demeanor..maybe I'll post it sometime.

I've said this before..here..but you docs see so many pts, but the pt sees just you and they look to you, they trust you and if surgery...they are trusting you with their very lives. I think every doctor should read your "Good Vibrations" post (Back in Feb?)and take it to heart.

The only thing that perplexes/concerns me about the surgical training is the sleep deprivation. On the one hand..you have to be able to suck it up, have the bladder of an elephant, endure the backaches, etc and persevere with excellence, BUT on the other hand there IS the REALITY/CONSEQUENCES of sleep deprivation which could seriously compromise the pt's well being.

I haven't read the comments as yet so forgive me if there is any duplication in comment/questions. :)

i recently had a comment on my blog strongly condemning the so called boot camp type training surgeons go through and i had a eureka moment. we don't work these hours because we want to prove some macho thing. we do it because we have no choice. the patient load, available surgeon ratio is wrong. and it will never get better. there will always be patients needing life saving surgeries in the wee hours and the number of surgeons training up is decreasing (few left willing to put themselves through the training and the lifestyle). so, if you are the surgeon on duty and some patient comes in when you're not nicely rested up, do you help him or get a good night's sleep and compromise his chances? that, in the end, is what it's all about. all the arguments that don't consider patient outcome with available resources (surgeons) should be ignored.

and, yes, sid, the south africans did thump the usa team in the rugby world cup. although your right wing (a zimbabwean born radiologist) ran around our star player (habana) to score a try. very very impressive to say the least. i wonder if he has a medical blog.

"My philosophy is that I pay as much attention in proportion to the level of interest that student shows in the material, after first giving a generous evaluation period to see how interested he is. If a student shows a lot of interest, I'll definitely spend a lot more time teaching him. "

Orac, this is the ideal situation for both teacher and student! As a 3rd year student, this sort of custom-teaching is highly appreciated. My question is this - in our school we are shuffled around so much that facetime with an attending might be limited to 1/2 day, period. We may work with 25 different attendings in a month (for example, in our ambulatory block) - so there is little time for a "generous evaluation period." What do you recommend in place of that, if your time with the student is so very capped?

Sid, I completely agree. I've been practicing veterinary medicine as a generalist for eight years now (and fwiw I was a veterinary nurse for many years before I went to veterinary school). I don't fancy myself a particularly brilliant surgeon by any stretch. Anything unusual gets turfed to a surgeon if the owner will go for it, or to a colleague in my own practice who is more interested in surgery if not. But of course there are times when it comes down to me and I have to step up to the plate because otherwise the pet isn't going to get his problem addressed at all. What do I do? I read about the surgery. I watch a training video if possible. I almost always bring reference material into the OR just in case. If possible I scrub in with someone else on a similar surgery beforehand, too. I can't imagine why anyone would ever want to step into an OR unprepared for all possibly predictable occurrences.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.